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Robert D. Seaman
General Counsel
TRICARE Management Activity
March 3, 2008
TRICARE MANAGEMENTACTIVITY UPDATE
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OBJECTIVES
• TMA Overview• TRICARE Acquisitions • MHS Clinical Quality and
Transparency• Selected Statutory
Changes to TRICARE
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TMA MISSION
• DoD Field Activity of the USD(P&R), Operating Under the Authority, Direction and Control of the ASD(HA) (DoDD 5136.12)
• Mission– Manage TRICARE– DoD Contracting Activity– Administer, Manage, and Execute Unified
Medical Program/DHP Appropriations– Support Services in Implementation of
TRICARE Program and CHAMPUS
Organizational StructureTRICARE Management Activity
Acting Chief MedicalOfficer
1Dr. Smith
Acting Chief MedicalOfficer
1Dr. Smith
Acting Chief FinancialOfficer
1Mr. Middleton
Acting Chief FinancialOfficer
1Mr. Middleton
Chief Information
Officer1Mr. Campbell
Chief Information
Officer1Mr. Campbell
Chief Force Health
Protection and Readiness
Programs 1Ms. Embrey
Chief Force Health
Protection and Readiness
Programs 1Ms. Embrey
General CounselMr. Seaman
General CounselMr. Seaman
Director, TMADr. S. Ward Casscells
Director, TMADr. S. Ward Casscells
Senior Enlisted Advisor (SEA)OASD (Health Affairs) & TMA
CMSgt Manuel Sarmina, USAF
Senior Enlisted Advisor (SEA)OASD (Health Affairs) & TMA
CMSgt Manuel Sarmina, USAF
Chief Health PlanOperations
Ms. Storck
Chief Health PlanOperations
Ms. Storck
Chief of StaffMr. Gidwani
Chief of StaffMr. Gidwani
Acting Regional Director
TRO NorthMr. Williams
Acting Regional Director
TRO NorthMr. Williams
Regional DirectorTRO South
1Mr. Gill
Regional DirectorTRO South
1Mr. Gill
Regional DirectorTRO West
1RADM Lescavage
Regional DirectorTRO West
1RADM Lescavage
Deputy Director, TMAMG Elder Granger, MC, USA
Deputy Director, TMAMG Elder Granger, MC, USA
DirectorTAO Latin Am/Can
1COL Franco
DirectorTAO Latin Am/Can
1COL Franco
DirectorTAO Pacific
Mr. Chan
DirectorTAO Pacific
Mr. Chan
DirectorTAO Europe1COL Bradley
DirectorTAO Europe1COL Bradley
Chief Pharmaceutical
Operations 2RADM McGinnis
Chief Pharmaceutical
Operations 2RADM McGinnis
1Non-TMA2Public Health Service
Director, Program IntegrationMs. Speight
Director, Program IntegrationMs. Speight
Director, DoD/VA Program
Coordination OfficeMr. Cox
Director, DoD/VA Program
Coordination OfficeMr. Cox
Executive OfficerLTC Wooldridge
Executive OfficerLTC Wooldridge
TRICARE MilitaryEducation/Executive Assistant to
SEA OASD (HA) & TMAHMCS Joseph Galang, USN
TRICARE MilitaryEducation/Executive Assistant to
SEA OASD (HA) & TMAHMCS Joseph Galang, USN
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TRICARE Overview
TRICARE is a comprehensive health benefits
program comprised of the military medical
treatment facilities and health care received
from private sector health care providers and
institutions, worldwide.• Uses the Military Healthcare Structure as the
Primary Healthcare Delivery System• Augmented by a Civilian Network of
Providers and Facilities (Purchased Care)• Serving Active Duty Service Members,
Reserve Components, Retirees and their Families and others Worldwide
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TRICARE Overview
TRICARE Administration
• Military Treatment Facilities are run by the Services Surgeons’ General• TMA develops overall policies and program guidance for the health benefit programs• TMA awards and administers contracts in
support of ASD(HA)’s administration of the purchased care portion of the TRICARE program
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TRICARE Overview
TRICARE Facts and Figures—Projected for FY 2007
Total Beneficiaries 9.2 million
Prime Enrollees 5.0 million
Pharmacy Benefit Users 6.6 million
115M Rx in FY06 = $6.18 B
Military Hospitals & Medical Centers 65
Medical Clinics 412
Dental Clinics 414
Total Military Health System Personnel 132,700
Total Unified Medical Program (UMP): $28.16 billion*
* Includes direct care and private sector care funding, military personnel, and military construction, but not the Medicare Eligible Military Retiree Healthcare Fund, $11.16 Billion.
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TRICARE Management Activity Acquisitions
Laurel Gillespie
Deputy General Counsel
TRICARE Management Activity
303-676-3705
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TRICARE Family of Programs
• Managed Care (includes overseas claims processing)• TRICARE for Life (TFL) and Senior Pharmacy• Pharmacy: -- Military Pharmacies
-- Purchased Care (Retail and Mail Order)• Overseas (TRICARE Overseas Program, Puerto Rico,
TRICARE Global Remote Overseas)• Dental: TRICARE Dental Plan (TDP) and Retiree Dental Plan• Reserve Health (TRICARE Reserve Select/Other)• Uniformed Services Family Health Plan (USFHP)• Demonstrations/Miscellaneous Programs (Women, Infants,
and Children – Overseas, Chiropractic, Continued Health Care Benefit Program, Counter Narcotics, Transitional Assistance Medical Program, Tobacco Cessation, Weight Management, etc.)
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Managed Care Contracts
• Fixed Price/Cost plus Incentive fees with positive and negative incentives– Financially Underwrite the Civilian Component of Care– Delivery of health care which is comparable to best offered in
civilian community– Partnership with MHS to optimize delivery of health care
services; beneficiary satisfaction; best value health care; access to data; and, minimal disruption to beneficiaries
– Contractor Provides: networks, referral management, MTF coordination, medical management, claims processing, customer service and ADP
– Uniform Benefit
• TRICARE Third Generation (T-3)– Fixed Price/Cost plus fixed fee and positive/negative incentives– Currently in draft – http://www.tricare.mil/contracting/healthcare/solicitations/
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Current Contracts
-Managed Care Contracts (3) – $6.5 B 5 Option Periods – Contracts Due To Expire 3/31/2009
-Designated Provider Contracts (6) -- $4.5B4 Option Periods – Contracts due to Expire 5/31/2008
-TRICARE Dental Contracts (2) TRDP and TDP- $2.4 B 5 Option Periods – TRDP Contract Due To Expire 9/30/20135 Option Periods – TDP Contract Due To Expire 1/31/2011
-TRICARE Dual Eligible Fiscal Intermediary Contract - $594 M 6 Option Periods – Contract Due To Expire 6/30/2014
-Mail Order Pharmacy Contract - $275 M ($.74B/year drug costs)5 Option Periods – Contract Due To Expire 2/29/2008.
-Retail Pharmacy Contract - $245.4 M ($3.89 B/year drug costs)5 Option Periods – Contract Due To Expire 3/31/2009
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-Puerto Rico Contract – $9.1 M 4 Option Periods -- Contract Due To Expire 7/31/2008
-Tobacco Quit Line Demo Contract - $5.4 M 2 Option Periods -- Contract Due To Expire 9/30/2008
-Weight Management Demo Contract - $8.3 M 2 Option Periods -- Contract Due To Expire 9/30/2008
-Health Information Technology - $933.2 M 4 Option Periods -- Contract Due To Expire 3/31/2010
-National Quality Monitoring Contract, NQMC - $24.5 M 4 Option Periods -- Contract Due To Expire 4/20/2009
-Claims Audit Review Services, CARS - $6.2 M 4 Option Periods -- Contract Due To Expire 2/20/2009
Current Contracts
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Current Solicitations
- TRICARE Quality Monitoring Contract (TQMC)Base Period and 5 Option Periods Through April 30, 2014
- TRICARE Claims Audit Review Services (TCARS)Base Period and 5 Option Periods Through January, 31, 2015
- Active Duty Dental Program (ADDP)Base period and 5 Option Periods Through June 20, 2014
- TRICARE Pharmacy (TPharm)Base Period and 6 Option Periods Through November 30, 2014
- TRICARE Overseas (TOP)Base Period and 5 Option Periods Through May 31, 2014
- 3 Managed Care Contracts (T-3) Base Period and 5 Option Periods Through March 31, 2015
- 6 Designated Provider ContractsBase Period and 7 Option Periods through May 31, 2016
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Sources of Authority
Government Contract Rules
– Federal Acquisition Regulation (FAR) 48 CFR Parts 1-52• The Basic Framework for Government Contract
Procurement and Administration– Defense Federal Acquisition Regulation
Supplement (DFARs) 48 CFR 201 et. Seq.– Statutes/Regs/Manuals– Case Law
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What’s Happening in 2008
• Potential litigation following contract award
• TMA attorney/paralegal teams prepare for likely bid protests
• Proactive counsel• Up front participation• Conclusion
MHS Clinical Quality and
Transparency
Carol J. Cooper
Associate General Counsel, TMA
703-681-6012
March 3, 2008
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Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs
It is the purpose of this order to ensure that health care programs administered or sponsored by the Federal Government promote quality and efficient delivery of health care through the use of health information technology, transparency regarding health care quality and price, and better incentives for program beneficiaries, enrollees, and providers. It is the further purpose of this order to make relevant information available to these beneficiaries, enrollees, and providers in a readily useable manner and in collaboration with similar initiatives in the private sector and non-Federal public sector.
Executive Order
22 August 2006
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Key Points for Transparency
• Release of MHS quality assurance data is governed by:– Title 10 §1102
• Event level data can not be released• Aggregate statistical data may be released but:
– It must be numerical with a numerator and denominator and – It must not Identify individual patients or individual providers
• The MHS monitors and uses nationally recognized, validated quality measures
• Some DoD aggregate statistical data, and some MTF level data is currently available to the public – for example– Aggregate DoD data in the annual MHS RTC on Clinical Quality– MTF JC quality (ORYX®) measures/patient safety goals on the JC
Quality Check website
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TITLE 10 U.S.C. §1102. Confidentiality of medical quality assurance records…
a) Confidentiality of Records.— Medical quality assurance records created by or for the Department of Defense as part of a medical quality assurance program are confidential and privileged. Such records may not be disclosed to any person or entity, except as provided in subsection (c). [Includes our QA, RM, PS and Peer Review Programs.]
(d) Disclosure for Certain Purposes.— (1) Nothing in this section shall be construed as authorizing or requiring the withholding from any person or entity aggregate statistical information regarding the results of Department of Defense medical quality assurance programs. *
(j) Definitions. – (1) “The term ‘medical quality assurance program’ means any activity carried out … by or for the Department of Defense to assess the quality of medical care…”
*[Aggregate statistical data is numerical data that constitutes all of the data in pre-defined common demographic groupings that have been assembled in order to facilitate its interpretation. The pre-defined common grouping (or denominator) must have at least 3 (3 or more) members or the numbers may not be released.]
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MHS Enterprise Wide Metrics
Selected HEDIS®
Breast Cancer Screening Colorectal Cancer Screening Cervical Cancer Screening Asthma - Appropriate Medications
for Asthma Diabetes - HbA1c Test Diabetes - HbA1c in Control Diabetes Patient - LDL Test Diabetes Patient - LDL < 100
mg/dL
JC ORYX®
Aspirin at arrival for AMI Aspirin at discharge for AMI
Beta-Blocker at arrival for AMI Beta-Blocker at discharge for AMI Percutaneous coronary
intervention within 120 mins. of arrival for AMI
CHF – Left ventricular function (LVF) assessment
CHF - Detailed Discharge Instructions
CHF – ACEI for LVSD PN- Pneumococcal vaccination
status PN– Antibiotic timing Neonatal mortality SIP –Timing of antibiotic
administration (surgical patients)
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HARMONIZING EFFORTS BETWEEN FEDERAL PARTNERS – VHA/HIS/DoD
• The goal is to have federal agencies report on the same measures in the same way.
• By December 2008 report to OMB on Departmental efforts to “harmonize” the core subset of AQA measures and measurement methodologies so as to reach consistency with other Departments. If “harmonization” not possible, report defines in explicit detail why it could not be accomplished.
• By December 2009, evaluate the ability to electronically extract harmonized quality measures from active sites.
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Factors Affecting Federal Agency Harmonization
• Different data availability in electronic systems
• Different patient populations• Different quality measures currently available
through abstraction• Different business rules resulting in different
denominator (eg: users vs. enrolled; attribution of resident patients)
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Way Forward with MHS Quality Performance Sharing
• Aggregate statistical data may be released outside of DoD if precautions are taken to protect the identity of and privacy of both patients and providers– Data may be released for an identified MTF or group of MTFs
only by DoD (QA reg allows the Services to release Service Data and DoD to release the MTF level data.)
• Continue work with other Federal agencies (VA and Indian Health Service) to “harmonize” quality performance measures
• Determine a set of measures currently or potentially collected appropriate for public release
• Determine the level of aggregation and the venue in which measures will be released – DSGs have in principal agreed to post facility-level data
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Purchased Care Quality Transparency
• Facility specific data is publicly available for ORYX/CMS measures and may be compared to facility specific MTF data on the JC Quality Check website
• Plan is to present available MHSPHP HEDIS-like measures rolled up to the regional level on the TMA website
• NQMC will be collating aggregated publicly reported CMS/JC data for network participating hospitals by region as an on-going deliverable – this data may also be posted to the TMA website when available
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Provider Level Performance Data
• Is used internally, but will not be published for MTF providers; in part due to interpretation of Title 10 §1102
• Contractor may internally use quality measures as a management tool for network providers and for patient channeling
• Network quality measures published publicly should be standardized across regions and to the extent possible should mirror data publicly published by TMA for the direct care system
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TJ McGrathAssociate General Counsel, TMA
NDAA 2007/2008Employer-Sponsored Group
Health Care PlansExpanded TRICARE Reserve
Select Program
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10 USC 1097c
• TRICARE program: relationship with employer-sponsored group health plans(a) Prohibition on Financial Incentives Not to Enroll in a Group Health Plan- (1) Except as provided in this subsection, the provisions of section 1862(b)(3)(C) of the Social Security Act shall apply with respect to financial or other incentives for a TRICARE-eligible employee not to enroll (or to terminate enrollment) under a health plan which would (in the case of such enrollment) be a primary plan under sections 1079(j)(1) and 1086(g) of this title in the same manner as such section 1862(b)(3)(C) applies to financial or other incentives for an individual entitled to benefits under title XVIII of the Social Security Act not to enroll (or to terminate enrollment) under a group health plan or a large group health plan which would (in the case of enrollment) be a primary plan (as defined in section 1862(b)(2)(A) of such Act).
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10 USC 1097c
• (f) Definitions- In this section:
(1) The term ‘employer’ includes a State or unit of local government.
(2) The term ‘group health plan' means a group health plan (as that term is defined in section 5000(b)(1) of the Internal Revenue Code of 1986 without regard to section 5000(d) of the Internal Revenue Code of 1986).
(3) The term `TRICARE-eligible employee’ means a covered beneficiary under section 1086 of this title entitled to health care benefits under the TRICARE program.
• (g) Effective Date- This section shall take effect on January 1, 2008.
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10 USC 1097c
• Permitted:– Cafeteria Plans– Service Contract Act Options
• Prohibited:– TRICARE Supplemental Plans
• Enforcement:– Civil monetary penalties not to exceed $5000 for
each violation – Remedies under the Debt Collection Improvement
Act, 31 U.S.C. 3701 et seq.
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10 USC 1076d
• History – TRICARE Reserve Select– NDAA 2005 – 90 day deployment in
support of a contingency– NDAA 2006 – 3 Tier System with staggered
premiums– NDAA 2007 – All Selected Reserves
except FEHB eligibles, effective October 1, 2007
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10 USC 1076d
• NDAA 2008– Sec 706 – Continuation of eligibility for
TRICARE Standard coverage for certain members of the Selected Reserve• Permits coverage under NDAA 2006 to run
before excluding reservists from coverage for being eligible for FEHB
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